Millions of people in the United States can’t live independently without assistance, often due to age or a disability. For people on Medicaid (or Medicaid and Medicare) who need help with activities of daily living, states provide coverage for long-term services and supports—services that are often contracted to managed care organizations (MCOs).  

Long-term services and supports (LTSS) include a range of medical and personal care services for people who need assistance with daily tasks such as getting dressed, making and eating meals, bathing, managing their medications, driving, etc. These services can take place in the home, in a community-based residence like a group home, or in an institution, and they can last anywhere from weeks to years.  

Long-term services and supports can be very expensive, and contrary to common belief, they are rarely covered by Medicare or private insurance.  In 2023, the median annual costs for LTSS were $68,640 for full-time home health aide care, nearly $117,000 for a private room in a nursing home, and $288,288 for 24-hour home health aide services, according to KFF.  A review of National Health Expenditure data estimated that the U.S. spent more than $400 billion on LTSS in 2022, and most of that ($284 billion) was for home and community-based services. Medicaid paid 61% of those costs.  

Not surprisingly, there is a pressing need for long-term services and supports in the U.S.: The Congressional Budget Office estimated that 5.8 million people in 2020 used Medicaid long-term services and supports in their home or community, and 1.8 million people used them in institutions.  

The value and need for LTSS is clear, even (or especially) as the healthcare industry has struggled with persistent workforce shortages—which only got worse during the COVID-19 pandemic. Medicaid officials in all 50 states reported shortages of home- and community-based services (HCBS) workers, especially personal care attendants, nursing staff, home health aides and direct support professionals, according to a KFF survey, and most (43 states) reported permanent closures of HCBS providers.  

State Medicaid Coverage of LTSS

State Medicaid agencies are required to offer coverage for institutional long-term services and supports; coverage for home- and community-based services (HCBS) is optional, though federal and state policymakers have moved to expand these services, since they are less expensive and often preferred by the members themselves. Three-fourths of people who used Medicaid LTSS in 2021 were receiving HCBS, which includes only the costs of services, not the cost of housing/rent or mortgage payments.  

Over the past three decades, the share of Medicaid LTSS spending for home and community-based services has nearly quintupled: In FY1989, it accounted for 12% of Medicaid LTSS spending; in FY2019, HCBS made up more than half (59%) of total Medicaid LTSS spending.

Covered services vary from state to state, and 24 states had contracted with managed care organizations to provide those long-term term services and supports as of December 2023, though industry leaders predict that number will grow.  

“Where MLTSS programs have been implemented, we know that patients and states have benefited from innovative services, holistic and coordinated care, and budget predictability,” said Craig Kennedy, President and CEO of Medicaid Health Plans of America in a report on the state of MLTSS. “As people live longer, interact with our healthcare system more frequently, and overwhelmingly prefer to age at home, the need and demand for MLTSS programs will undoubtedly increase.”

Dual-Eligible Populations, MLTSS, and Transportation Benefits

For people who are eligible for both Medicare and Medicaid, state and federal policymakers have worked to align managed long-term services and support programs with Medicare managed care, since managing the broad range of services and populations can require significant state resources.  

In Pennsylvania, for example, the state Community HealthChoices program was established in 2018 to deliver long-term services to dual-eligible members and people with physical disabilities who receive home and community-based waiver services or nursing facility care. The program served about 411,000 people as of October 2023, with services provided by MCOs including AmeriHealth Caritas, PA Health and Wellness (a Centene subsidiary), and the University of Pittsburgh Medical Center Community HealthChoices.  

According to the Pennsylvania Department of Human Services, “CHC was developed to enhance access to and improve coordination of medical care, while at the same time creating a person-driven, long-term support system in which people have choice, control and access to a full array of quality services that provide independence, health, and quality of life.”  

Each MCO has developed innovative ways to improve care to the duals population enrolled in CHC, with added financial incentives from the Pennsylvania Department of Human Services for MCOs that meet quality goals. For example, AmeriHealth Caritas reported successful efforts to transition people from nursing homes to home or community care with early intervention and data, comprehensive care coordination, focused housing initiatives, a focus on wraparound services and collaboration with community partners.  

In addition to benefits associated with LTSS, CHC covers non-emergency medical transportation (NEMT, a mandatory benefit under Medicaid) as well as transportation to non-medical destinations such as grocery stores and churches that can contribute to overall health and help people avoid feeling socially isolated.  

SafeRide Health has years of experience providing transportation for dual-eligible members. In Texas, for example, SafeRide provides more than 65,000 rides a month for members of one Medicaid/Medicare plan that covers Long Term Services and Supports. In August 2024 (the latest monthly data available), SafeRide had a fulfillment rate of 99% and an on-time rate of 97% for those rides.  

“Transportation is such an important factor for these members, since they have frequent medical appointments and often require special transportation assistance,” said Brian Gebhardt, SafeRide Health Chief Operating Officer. “We work with our health plan partners to ensure that every member has access to the care they need. SafeRide can also be a lifeline to the social resources and connections that can improve health outcomes and quality of life.”  

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